Thank you for your interest in attending the 17th Annual Family Leadership! 
 
Scholarships are reserved for parents or caregivers of a child with a disability, special needs or at-risk for developmental delay and youth with disabilities ages birth-26.  

If you have any questions or concerns, please call Belinda Vigil at 505-247-0192 or email bvigil@parentsreachingout.org

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* 1. I am a: 

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* 2. First Name:

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* 3. Last Name:

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* 4. Spouse Information (Please write N/A if you are not including them in your scholarship application):

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* 5. Address:

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* 6. City:

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* 7. State:

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* 8. Zip:

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* 9. Telephone:

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* 10. Cell:

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* 11. E-mail:

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* 12. Ethnicity:

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* 13. Language Preference: 

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* 14. List all children that will be attending including date of birth:

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* 15. Please list the total number of people you are including in your scholarship application (only list those who will be attending the conference: 

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* 16. Have any of your children received Early Intervention (EI) Services?

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* 17. If “yes”, What agency:

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* 18. Does your child have a disability; special needs or is at risk?

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* 19. If “yes” please specify and provide additional information about your child’s condition:

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* 20. Tell us about any challenges you have experienced in navigating early intervention, special education or health care:

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